312700033-12-14-2023-59-AS-MSEY-CYNR9J-20231219114935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700033
Report Date: 12/14/2023
Date Signed: 12/14/2023 11:17:58 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2023 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20230802143046

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	JESSICA SANDERS		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS: 27	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jackie Hernandez		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staffing shortage
Lack of supervision

INVESTIGATION FINDINGS:

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LPA Parks arrived on Thursday December 14, 2023, to conclude a complaint investigation regarding the above allegations. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Wellness Director, Med techs, caregivers, and dietary staff. Additionally, LPA interviewed R1’s hospice nurse and Administrator of current facility. LPA reviewed R1’s facility file in addition staffing schedules and employee timecards. The result of the investigation is as follows:

LPA reviewed documentation which showed R1 had a weight loss of 21.6 pounds from May 4, 2023 through August 1, 2023. According to staff interviews, R1 required assistance with eating. This assistance varied from helping R1 get started with their meal to assisting with the entire meal. Staff acknowledged that R1 had a good appetite and usually ate most of their food. LPA interviewed a family friend of R1 who visited towards the end of R1’s stay at this facility. This family friend reported that no one was assisting R1 with their meal.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 59-AS-20230802143046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC	FACILITY NUMBER: 312700033
	VISIT DATE: 12/14/2023

NARRATIVE

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As they began to assist R1, they drank 3 glasses of liquid and ate all of their food. This complaint does not have specific allegations about the food or service provided by the dietary department, rather that there were not sufficient staff to assist R1 with their meals resulting in weight loss. R1 later moved to a 6-bed facility. LPA interviewed R1’s hospice nurse who stated that R1 has had a documented weight gain since being at this new facility.

LPA interviewed staff who acknowledged that there are typically 3 caregivers in the morning and evening shifts along with a med tech scheduled. NOC shift typically has 2 caregivers and one med tech scheduled. LPA reviewed the facility’s census for the months of July, August, and September 2023. LPA reviewed staffing schedules vs. timecards for July 27, 2023 where the complainant alleged that there was insufficient staffing. LPA found that there were 2 caregivers and one med tech for the morning shift. The census this date was 37 residents. Upon review of timecards, LPA found that there is a pattern of less than stated staffing during weekends. According to staff interviewed, management often found it difficult to find replacements when staff were unable to work their scheduled shift. Additionally, staff stated that management would rarely help staff with residents when they were short staffed.

Based on the information detailed above, LPA finds the allegations to be substantiated. A finding that the allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

LPA previously cited the facility for insufficient supervision and lack of staffing on 12/6/2023 for complaint control # 59-AS-20231003164146. Due to the timeline of when this complaint was received and completed, although the allegations are substantiated, there will not be any citations given.

Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2023 and conducted by Evaluator Melissa Parks

COMPLAINT CONTROL NUMBER: 59-AS-20230802143046

FACILITY NAME:	GRANITE BAY COUNTRYHOUSE LLC		FACILITY NUMBER:	312700033
ADMINISTRATOR:	JESSICA SANDERS		FACILITY TYPE:	740
ADDRESS:	8485 BARTON RD		TELEPHONE:	(916) 899-6565
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	49	CENSUS:	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Jackie Hernandez		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Dietary services/food services

INVESTIGATION FINDINGS:

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LPA Parks arrived on Thursday December 14, 2023, to conclude a complaint investigation regarding the above allegation. LPA met with Interim Executive Director Jackie Hernandez and explained the purpose of the visit.

Throughout the course of the investigation, LPA interviewed the previous Administrator, previous Wellness Director, Med techs, caregivers, and dietary staff. Additionally, LPA interviewed R1’s hospice nurse and Administrator of current facility. LPA reviewed R1’s facility file in addition staffing schedules and employee timecards. The result of the investigation is as follows:

LPA reviewed facility weekly menus from 4/2 until 9/24. Daily menus showed a variety of food for breakfast including scrambled eggs, sausage casserole, waffles, fruit of the day, and assorted hot and col cereals. Lunches showed a variety of entrees including pan seared fish, Shepards pie, meatloaf, and roast pork. Dinner showed a selection of entrees including spaghetti, crab salad, roast beef sandwich and teriyaki chicken burgers. Weekly menus show that fruit is available for breakfast. Additionally, each lunch

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20230802143046

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRANITE BAY COUNTRYHOUSE LLC	FACILITY NUMBER: 312700033
	VISIT DATE: 12/14/2023

NARRATIVE

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and dinner meal was served with a vegetable. Care and kitchen staff stated that fresh fruit and vegetables are served daily. Furthermore, staff stated that there is always extra food available should a resident want additional servings.

Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,

Exit interview. A copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4